FIRM NAME
NAME OF BUSINESS (official name and d/b/a)
BUSINESS HEADQUARTERS ADDRESS
CITY / STATE / ZIP CODE
TELEPHONE
() - / FAX
() -
NAME OF DIVISION OR SUBSIDIARY (if there is a parent firm)
BILLING ADDRESS
CITY / STATE / ZIP CODE
NAME OF CHIEF EXECUTIVE OFFICER
CUSTOMER CONTACT / TITLE
ADDRESS / EMAIL
TELEPHONE
() - / TOLL-FREE NUMBER
() - / FAX
() -
COMPANY WEB SITE
TYPE OF ORGANIZATION
-select option-IndividualSole proprietorPartnershipLegal services corporationTax-exemptCorp. provide/bill medical/health care serviceCorp. NOT provide/bill medical/health care serviceGovernmentalNonredisdent alienEstate or trustPharmacy (non-corp.)Pharmacy/funeral home/cemetary (corp.)Limited Liability Company / APPLICABLE TAX CLASSIFICATION
-select option if LLC-D=disregarded entityC=corporationP=partnership
LENGTH OF TIME IN BUSINESS
ANNUAL SALES(for most recently completed Fiscal Year)
NUMBER OF FULL-TIME EMPLOYEES(average from most recent Fiscal Year)
TYPE OF & DESCRIPTION OF BUSINESS
STATE OF INCORPORATION, STATE OF FORMATION OR STATE OF ORGANIZATION
MAJOR OFFICE(identify & specify the locations(s) and telephone #(s) & other facilities that relate to the consultant’s performance under the terms of this solicitation)
DEPARTMENT OF HUMAN RIGHTS (DHR) PUBLIC CONTRACT NUMBER
If the CONSULTANT has employed 15 or more full-time employees at any time during the 365-day period immediately preceding the publication of this solicitation in the Transportation Procurement Bulletin (or issuance date if not published), then the CONSULTANT must have a current Public Contract Number or have proof of having submitted a completed application for one prior to the Solicitation opening date (44 Ill. Adm. Code 750.210(a)). For application information call the DHR Public Contracts unit at (312) 814-2431.
DHR NUMBER(or attach proof of application)
DISCLOSURE OF BUSINESS OPERATIONS WITH IRAN (30 ILCS 500/50-36)
Each bid, offer, or proposal submitted for a State contract, other than a small purchase defined in Section 20-20 [of the Illinois Procurement Code], shall include a disclosure of whether or not the bidder, offeror, or proposing entity, or any of its corporate parents or subsidiaries, within the 24 months before submission of the bid, offer, or proposal had business operations that involved contracts with or provision of supplies or services to the Government of Iran, companies in which the Government of Iran has any direct or indirect equity share, consortiums or projects commissioned by the Government of Iran and:
- more than 10% of the company’s revenues produced in or assets located in Iran involve oil-related activities or mineral-extraction activities; less than 75% of the company’s revenues produced in or assets located in Iran involve contracts with or provision of oil-related or mineral – extraction products or services to the Government of Iran or a project or consortium created exclusively by that Government; and the company has failed to take substantial action; or
- the company has, on or after August 5, 1996, made an investment of $20 million or more, or any combination of investments of at least $10 million each that in the aggregate equals or exceeds $20 million in any 12- month period that directly or significantly contributes to the enhancement of Iran’s ability to develop petroleum resources of Iran.
A bid, offer, or proposal that does not include this disclosure shall not be considered responsive. We may consider this disclosure when evaluating the bid, offer, or proposal or awarding the contract.
You must check one of the following items and if the second item is checked you must also make the necessary disclosure:
There are no business operations that must be disclosed to comply with the above cited law.
The following business operations are disclosed to comply with the above cited law:
Page 1 of 2 LA-RFP-02 (Rev. 9/29/17)